Hair Loss#

Hair loss is generally split into two categories. This distinction matters because it determines how urgently you need to be seen and whether hair can grow back.

• Non-scarring (the follicle is still intact). Hair can regrow on its own or with treatment. Most hair loss falls in this group:
  • Male-pattern and female-pattern hair loss (androgenetic alopecia).
  • Telogen effluvium (stress-related shedding).
  • Alopecia areata (patchy, autoimmune).
  • Traction alopecia (from tight hairstyles).
  • Nutritional and medical causes (iron deficiency, thyroid disease, B12 deficiency, etc.).
• Scarring (cicatricial) alopecia. The follicle is permanently damaged. Once lost, the hair does not grow back. This is uncommon but important to recognise early because dermatology assessment can preserve remaining hair if started promptly. Signs that suggest scarring: redness, scaling, burning, itch, or smooth shiny patches where the follicle openings are gone.

If you see redness, scaling, painful patches, or rapidly progressing bald spots, see a dermatologist promptly rather than going through a virtual consultation first.

By a wide margin: androgenetic alopecia (male- and female-pattern hair loss). This is hereditary, hormone-driven, and follows a recognisable pattern (receding hairline and crown thinning in men; widening part and diffuse thinning at the top in women).

The second most common cause clinicians see is telogen effluvium - diffuse shedding triggered by stress, illness, postpartum changes, or medication.

Telogen effluvium is a temporary form of hair loss in which a large number of hair follicles shift early into the resting (telogen) phase, then shed all at once a few months later. It typically presents as diffuse shedding across the entire scalp - you may notice more hair in the shower, on your pillow, or when brushing.

Triggers include:

• Severe physical or emotional stress.
• Major illness, high fever, COVID infection.
• Surgery, including pregnancy and delivery (postpartum shedding).
• Significant weight loss or restrictive diet.
• Starting or stopping certain medications (some blood-pressure medications, antidepressants, hormonal contraceptives, retinoid acne medications).
• Iron deficiency, vitamin D deficiency, thyroid disease.

Timeline: Shedding usually starts 2-3 months after the triggering event and continues for several months. Hair then regrows on its own as the cycle resets.

When the increased shedding persists for more than 6 months, it is called chronic telogen effluvium. Causes can be the same as acute but ongoing - persistent stress, an unresolved medical issue (thyroid, iron), or a continuing medication effect. Sometimes no specific cause is found.

Diagnosis involves history, scalp examination, and lab testing to look for treatable contributors. Even when the cause isn't identified, many cases improve over time once major stressors resolve.

Mainly the scalp. In some cases, eyebrows, eyelashes, or body hair can also thin. If you notice widespread hair loss across the whole body (including legs, arms, underarms), other causes need to be considered - this is less typical of telogen effluvium.

• Address the trigger. If the cause is identifiable (iron deficiency, thyroid, medication, sleep deprivation, dietary restriction), treating it is the most important step.
• Time. Most telogen effluvium resolves on its own once the trigger is gone. Regrowth takes 6-12 months to look normal again.
• Nutritional support. Eating enough protein, iron-containing foods, and not following extreme calorie restriction.
• Over-the-counter topical hair-loss treatment can shorten the shedding phase and accelerate regrowth in some patients. The clinician can advise on whether to add it.
• Avoid harsh hair practices during recovery (tight hairstyles, frequent heat styling, chemical relaxers, aggressive brushing of wet hair).

The deficiencies with the best evidence for causing or contributing to hair loss:

• Iron deficiency. Iron is essential for hair-follicle function. Low iron stores (measured as ferritin) are a common reversible cause, especially in menstruating women, vegetarians/vegans, athletes, and after pregnancy.
• Vitamin D deficiency. Lower vitamin D levels have been associated with diffuse shedding and with alopecia areata. Correcting deficiency may help.
• Vitamin B12 deficiency. Common in vegetarians, vegans, older adults, and people on long-term acid-blocker medication. Diffuse shedding can be one of several non-specific symptoms.
• Folate (B9) deficiency. Less common in Canada because of food fortification, but possible.
• Zinc deficiency. Less common; relevant in eating disorders, bariatric surgery, and certain GI conditions.
• Protein under-consumption. Strict calorie or protein restriction can cause shedding.

Less convincing evidence, despite popular claims:

• Vitamin C, vitamin E, selenium, copper, biotin - generally not deficient in people eating a normal Canadian diet, and routine testing or supplementation isn't supported as a hair-loss treatment unless deficiency is documented. Excess biotin in supplements can also interfere with several common lab tests (TSH, troponin, hormones).

Both underactive thyroid (hypothyroidism) and overactive thyroid (hyperthyroidism) can cause diffuse hair shedding. Other symptoms (weight change, energy, temperature tolerance, periods, mood) usually point to thyroid as the cause. A TSH blood test is a simple screen.

Hair recovers once thyroid hormone levels are normal, but recovery can take 6-12 months after treatment starts.

Many medications can contribute to shedding. Common offenders:

• Some blood-pressure medications.
• Some antidepressants.
• Hormonal contraceptives (starting or stopping).
• Acne retinoid medication.
• Some seizure medications.
• Chemotherapy (causes a different pattern - anagen effluvium - usually within weeks of starting).
• High-dose vitamin A.
• Blood thinners.

If you started a new medication in the months before shedding began, mention it in your consultation. Don't stop prescribed medication without discussing it first.

Female-pattern hair loss (androgenetic alopecia in women) is diffuse thinning at the top of the scalp, often with a widening centre part. The frontal hairline is typically preserved (unlike in men, where the hairline recedes).

It is hereditary and partially driven by androgens, although the hormonal contribution in women is less clear-cut than in men.

• Family history of female- or male-pattern hair loss on either side.
• Postmenopausal women.
• Women with polycystic ovary syndrome (PCOS) or other conditions involving raised androgens.
• Onset can be anywhere from the 20s onward, more commonly after perimenopause.

• The over-the-counter topical hair-loss treatment is approved for women and is the standard first-line treatment. There's a women's-strength formulation that is well-studied.
• Underlying medical contributors need to be addressed first - iron deficiency, thyroid disease, post-pregnancy shedding, medication effect.
• For PCOS-related thinning, treating the underlying PCOS (lifestyle changes, hormonal management) often helps.
• The oral 5-alpha reductase inhibitor used in men's hair loss is not approved for women and is not standardly prescribed for women's hair loss; TeleTest does not currently prescribe this for women.

If hair loss is significant and isn't responding to first-line treatment, the clinician can suggest seeking out a local dermatologist with hair-loss expertise (your family doctor can arrange that referral - TeleTest does not arrange dermatology referrals).

Alopecia areata is an autoimmune condition in which the immune system attacks hair follicles, causing smooth, well-defined round or oval patches of hair loss. The patches can appear suddenly, are usually painless, and the skin underneath looks normal (no redness, scaling, or scarring).

It can affect any hair-bearing area, including beard, eyebrows, eyelashes, and body hair. Severe forms involve the entire scalp (alopecia totalis) or the whole body (alopecia universalis).

Genetic susceptibility plus an immune trigger. It is more common in people who have other autoimmune conditions (thyroid disease, vitiligo, type 1 diabetes) or a family history of autoimmune conditions.

Alopecia areata is generally treated by dermatology. First-line treatments (corticosteroid injections into the patches, prescription topical steroids, immunotherapy) are best managed with in-person dermatology assessment.

TeleTest can:

• Order baseline bloodwork (TSH, complete blood count, vitamin D, ferritin) if relevant to your situation.
• Discuss the diagnosis if it's clearly typical (patchy, smooth, well-defined) and provide guidance on what to expect.
• Provide a written summary of your hair-loss history to bring to a local in-person clinician.

TeleTest does not arrange dermatology referrals - your family doctor can refer you, or you can book directly with a local dermatology clinic. For sudden onset of any patchy hair loss, see a dermatologist.

Scarring (cicatricial) alopecia is a group of conditions in which inflammation permanently destroys hair follicles. Once destroyed, the follicle does not regrow hair. There may be redness, scaling, burning, itching, pain, or smooth shiny patches.

Why this matters: early treatment can stop the inflammation and preserve remaining hair, but it cannot bring back hair that's already gone. Prompt dermatology assessment is the priority.

Warning signs that suggest scarring alopecia:

• Hair loss with redness or scaling of the scalp.
• Burning, painful, or markedly itchy patches.
• Smooth, shiny patches where follicle openings have disappeared.
• Rapidly progressing bald patches.
• Beard or facial-hair patches developing alongside scalp patches.

If you have any of these, see a dermatologist promptly rather than going through a virtual consultation.

• Assessment of typical, non-urgent patterns of hair loss (male-pattern, female-pattern, telogen effluvium, suspected medication or nutritional contributions).
• Evidence-based bloodwork - TSH, ferritin, vitamin D, vitamin B12, CBC, and others when indicated by your situation. See the lab testing section.
• Prescription medications for male-pattern hair loss (oral and topical options), plus advice on the over-the-counter topical.
• Advice on over-the-counter topical for female-pattern hair loss and telogen effluvium.
• A written summary of your assessment and treatment history when in-person dermatology assessment is the next step (TeleTest does not arrange dermatology referrals).

• Diagnose or treat scarring alopecia. This needs in-person dermatology assessment with scalp examination and often a biopsy.
• Perform scalp biopsies, dermatoscopy, or in-person scalp exams. Virtual care can't replace these for ambiguous diagnoses.
• Treat alopecia areata beyond initial bloodwork and a written summary.
• Perform or arrange hair transplants.
• Prescribe the oral 5-alpha reductase inhibitor for women at standard hair-loss doses.

If your situation falls outside what we can offer, the clinician will say so and help you find the right provider.

Ferritin reflects the body's iron stores. Low ferritin is common in menstruating women, athletes, vegetarians, vegans, and after pregnancy, and is a treatable contributor to diffuse shedding.

• Useful for diffuse shedding, postpartum shedding, and in women with heavy periods.
• Caveat: ferritin can be artificially raised by inflammation, infection, or liver disease - so a normal level isn't always reassuring if you're acutely unwell.

Iron supplementation, when ferritin is low, can support hair recovery alongside treating the cause of low iron.

Useful in any diffuse hair loss because both underactive and overactive thyroid can cause shedding. Symptoms like fatigue, weight change, temperature intolerance, or menstrual changes raise the suspicion.

Vitamin D deficiency has been associated with both diffuse shedding and alopecia areata. It's reasonable to check, especially during winter months in Canada, in people with limited sun exposure, or in patients with darker skin.

Note: Vitamin D is not covered by provincial health plans in most situations and is a self-pay (uninsured) test.

Worth checking in vegetarians, vegans, older adults, people on long-term acid-blocker medication, or anyone with neurologic symptoms (numbness, tingling, balance issues).

A general screen for anemia and other issues that can present with diffuse shedding. Often ordered alongside the others.

ANA testing is sometimes asked about because some autoimmune conditions can cause hair loss. However, ANA is not routinely useful in hair-loss assessment:

• ANA can be positive at low levels in many healthy people with no autoimmune disease.
• Positive results lead to anxiety and unnecessary further testing.
• If lupus or another autoimmune condition is suspected based on other symptoms (rash, joint pain, fatigue, mouth sores), in-person assessment by your family doctor (who can arrange a rheumatology referral) is more appropriate than ANA testing alone.

TeleTest does not arrange ANA testing at this time.

DHT is the hormone that drives male- and female-pattern hair loss at the follicle. However, blood DHT levels do not correlate well with hair-loss severity. The key factor is follicle sensitivity to DHT, which is genetic and isn't measurable by a blood test.

For most people, DHT testing won't change the treatment plan. TeleTest does not routinely recommend DHT testing. If you're on a 5-alpha reductase inhibitor and want to see whether your dose is suppressing DHT, the clinician can discuss whether testing makes sense in your specific case.

Note: DHT is an uninsured (self-pay) test in Canada.

Routine testosterone and DHEAS testing for all women with hair loss is not recommended. These tests are useful when there are specific signs of excess androgens:

• Unwanted facial or body hair growth (hirsutism).
• New or persistent acne.
• Irregular or absent periods.
• Deepening voice or rapid masculinising changes (sudden onset warrants urgent evaluation).

Without these signs, testing rarely changes management and frequently leads to follow-up imaging (e.g., adrenal ultrasound) that turns out to be unnecessary - which carries cost, radiation, and anxiety.

Tests that measure minerals in hair shaft samples are not scientifically validated for diagnosing hair loss or guiding treatment. Results vary widely between labs and don't reflect body mineral status reliably. TeleTest does not offer this test or use it to guide treatment.

• Zinc is occasionally useful if a deficiency is suspected (eating disorders, malabsorption, bariatric surgery).
• Selenium, copper, biotin are rarely deficient in people eating a normal Canadian diet and are not routinely useful in hair-loss workup.

The average adult sheds about 50-100 hairs per day. This is part of the normal hair cycle - shed hairs are replaced over months. Shedding more than this consistently (visible clumps in the shower, on the pillow, when brushing) suggests something has shifted the cycle.

No. Hair grows slowly. Realistic timelines for treatments:

• Telogen effluvium recovery: 6-12 months once the trigger is removed.
• Topical hair-loss treatment: 3-6 months to see early effects; full effect at 12 months.
• Oral 5-alpha reductase inhibitor: 6-12 months for visible benefit; full effect at 12-24 months.
• Treating iron or thyroid deficiency: 6-12 months for visible regrowth after labs normalise.

Photo comparison at 6 and 12 months is more reliable than week-to-week perception.

Postpartum shedding is a form of telogen effluvium triggered by the hormone shifts after delivery. It typically starts 2-4 months postpartum and resolves over the following 6-12 months. It is normal, expected, and almost always resolves on its own.

If shedding persists beyond a year, is severe, or is associated with other postpartum symptoms (fatigue, weight change, mood changes), it's worth checking thyroid function and ferritin - postpartum thyroiditis and iron deficiency are both common after pregnancy.

Yes - severe physical or emotional stress can trigger telogen effluvium. Day-to-day life stress at typical levels is less likely to cause clinically obvious shedding, but major life events (bereavement, divorce, job loss, serious illness) can. Recovery follows the same timeline as other forms of telogen effluvium.

Many patients reported diffuse shedding starting 2-3 months after a COVID infection. This is consistent with telogen effluvium triggered by the illness itself (and possibly the systemic inflammation). It typically resolves over 6-12 months without specific treatment.

Yes - in the sense that severe calorie or protein restriction can cause shedding. Eating enough total calories, adequate protein, iron-containing foods, and a varied diet covers the nutritional bases for hair. Specific "hair vitamins" and supplements are mostly marketing in the absence of a documented deficiency. The exception is correcting actual deficiencies (iron, vitamin D, B12) when they're present.

Biotin supplementation only helps in true biotin deficiency, which is rare. For typical hair loss, biotin supplements have not been shown to improve hair growth.

Important: high-dose biotin can interfere with several common laboratory tests (TSH, troponin, several hormone tests). Stop biotin supplements at least 3-7 days before bloodwork to avoid misleading results.

• Most hair-loss bloodwork (TSH, ferritin, CBC, B12) is covered when there's a clinical indication.
• Vitamin D and DHT are usually not covered and are self-pay (uninsured) tests.
• Hair-loss medications (both oral and topical, prescription and over-the-counter) are usually not covered by provincial drug plans.
• The TeleTest consultation fee is not covered by provincial health plans.